What does cholelithiasis (gallstones) without evidence of acute cholecystitis (inflammation of the gallbladder) mean?

Cholelithiasis Without Evidence of Acute Cholecystitis: Meaning and Clinical Significance

Cholelithiasis without evidence of acute cholecystitis means gallstones are present in the gallbladder without signs of active inflammation of the gallbladder wall. 1, 2

Diagnostic Criteria and Differentiation

Cholelithiasis (Gallstones)

• Ultrasound is highly accurate at diagnosing gallstones with a reported accuracy of 96% 1
• Gallstones appear as echogenic foci within the gallbladder lumen that typically cast acoustic shadows 2
• The number, size, and mobility of stones should be documented in imaging reports 2

Absence of Acute Cholecystitis Features

When cholelithiasis is present without acute cholecystitis, the following inflammatory signs are absent:

• Gallbladder wall thickening >3mm (normal is <3mm) 1, 2
• Pericholecystic fluid 1
• Sonographic Murphy's sign (focal tenderness over the gallbladder) 1, 2
• Gallbladder distension 1, 2
• Adjacent liver hyperemia (an early finding in acute cholecystitis) 1

Clinical Significance

Natural History

• For patients with asymptomatic gallstones, the rate of developing moderate-to-severe symptoms or complications is estimated to be between 2% and 6% per year 3
• This leads to a cumulative rate of 7% to 27% in 5 years for progression to symptomatic disease 3
• The rate is likely higher for patients who already have mild symptoms 3, 4

Management Approach

• Asymptomatic patients with incidentally discovered gallstones generally do not require intervention 5, 4
• Patients with mild dyspepsia or flatulence that is not clearly biliary in origin should be observed rather than undergo cholecystectomy 5
• Patients with typical biliary pain (episodic right upper quadrant or epigastric pain, often after fatty meals) should be considered for cholecystectomy even without acute inflammation 4, 6

Diagnostic Evaluation

Ultrasound Findings

• Normal gallbladder wall thickness (<3mm) 2
• Presence of mobile gallstones 1, 2
• Normal common bile duct diameter (<6mm, or <8-10mm in elderly) 2
• Absence of pericholecystic fluid 1
• Absence of sonographic Murphy's sign 1, 2

Additional Considerations

• Common bile duct should be evaluated for stones (choledocholithiasis) 2
• Direct visualization of common bile duct stones on ultrasound is a strong predictor of choledocholithiasis, though sensitivity is limited (22.5-75%) 2
• If common bile duct stones are suspected despite negative ultrasound, additional imaging such as MRCP may be warranted 2

Treatment Options

Observation (Watchful Waiting)

• Appropriate for truly asymptomatic patients 3, 5
• No therapy may ever be required in many cases 3

Surgical Management

• Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones 4, 6
• Early laparoscopic cholecystectomy (within 72 hours of diagnosis) is recommended for acute cholecystitis but not necessary for uncomplicated cholelithiasis 1, 7
• About 5% of cholecystectomy patients have residual symptoms or retained common duct stones 3

Medical Management

• Ursodiol (ursodeoxycholic acid) may be considered for dissolution therapy in select patients who refuse surgery or are poor surgical candidates 3, 5
• Partial stone dissolution within 6 months of beginning ursodiol therapy appears to be associated with >70% chance of eventual complete dissolution 3
• Stone recurrence after dissolution with ursodiol was observed in 30% of patients within 2 years 3

Special Considerations

Risk Factors for Complications

• Multiple or large stones increase risk of developing symptoms 4
• Elderly patients have higher surgical risk if cholecystectomy becomes necessary 3
• Mortality rates for cholecystectomy increase with age and presence of comorbidities 3

Monitoring

• For patients with asymptomatic gallstones who choose observation, no specific monitoring protocol is required 5
• For those on dissolution therapy, serial ultrasonographic examinations should be obtained to monitor for recurrence 3

Common Pitfalls

• Relying solely on sonographic Murphy's sign for diagnosis of acute cholecystitis (low specificity) 1, 2
• Misinterpreting increased common bile duct diameter as definitive evidence of choledocholithiasis, especially in elderly patients 2
• Attributing nonspecific abdominal symptoms to gallstones without clear biliary pattern 5, 4